Documente Academic
Documente Profesional
Documente Cultură
PII: S0272-7358(16)30517-7
DOI: doi: 10.1016/j.cpr.2017.05.004
Reference: CPR 1611
To appear in: Clinical Psychology Review
Received date: 25 December 2016
Revised date: 24 May 2017
Accepted date: 29 May 2017
Please cite this article as: Maya Asher, Anu Asnaani, Idan M. Aderka , Gender differences
in social anxiety disorder: A review, Clinical Psychology Review (2017), doi: 10.1016/
j.cpr.2017.05.004
This is a PDF file of an unedited manuscript that has been accepted for publication. As
a service to our customers we are providing this early version of the manuscript. The
manuscript will undergo copyediting, typesetting, and review of the resulting proof before
it is published in its final form. Please note that during the production process errors may
be discovered which could affect the content, and all legal disclaimers that apply to the
journal pertain.
ACCEPTED MANUSCRIPT
PT
Maya Asher Anu Asnaani Idan M. Aderka
RI
University of Haifa University of Pennsylvania University of Haifa
SC
NU
MA
E D
PT
CE
AC
Author Note
1
ACCEPTED MANUSCRIPT
Abstract
Gender differences in social anxiety disorder (SAD) have not received much
empirical attention despite the large body of research on the disorder, and in contrast to
PT
literature regarding gender differences in eight domains of SAD: prevalence, clinical
RI
physiological arousal, and the oxytocin system. Findings from the present review indicate
SC
that women are more likely to have SAD and report greater clinical severity.
Notwithstanding, men with the disorder may seek treatment to a greater extent. According to
NU
the present review, the course of SAD seems to be similar for men and women, and findings
MA
highlight areas requiring future research and discuss the findings in the context of a number
findings with existing theories is essential in order to increase our understanding and
PT
tailored interventions for both men and women with the disorder.
CE
2
ACCEPTED MANUSCRIPT
1. Introduction
Social anxiety disorder (SAD) is a common and debilitating psychiatric disorder with an
marked and persistent fear of one or more social situations (e.g., talking to a stranger or peer,
going to a party) or performance activities (e.g., giving a speech) in which the person is
exposed to unfamiliar people, or where they may face possible scrutiny by others (American
PT
Psychiatric Association, 2013). Individuals with SAD fear they will act in a way (or show
RI
anxiety symptoms) that will be embarrassing and may lead to a negative evaluation by others
SC
(Alden & Taylor, 2010). As a result, they tend to avoid social situations, or endure them with
significant distress.
NU
The difficulties in interpersonal interactions described above result in significant
impairment in almost all facets of daily life, including relationships, work, and studies (e.g.,
MA
Aderka et al., 2012; Alden & Taylor, 2004). Compared to individuals without SAD, those
with the disorder are more likely to drop out of school prematurely (Stein & Kean, 2000), to
D
have lower educational attainment (Katzelnick & Greist, 2001; Wittchen, Stein & Kessler,
E
1999), to hold jobs below their level of qualification (Katzelnick & Greist, 2001), to have
PT
lower income and to be unemployed (Lecrubier et al., 2000), and even when employed, tend
CE
to miss 8 times more work days (Wittchen, Fuetsch, Sonntag, Mller, & Liebowitz, 2000).
Individuals with SAD report poor quality of life (Alonso et al., 2004), are more likely to
AC
attempt suicide (Wunderlich, Bronisch, & Wittchen, 1998), and are more likely to have
alcohol and nicotine dependence (Wittchen et al., 1999). Thus, SAD results in significant
Considering the large body of research on SAD, and despite accumulating data about
gender differences in other disorders (e.g., agoraphobia: Bekker, 1996; specific phobias:
3
ACCEPTED MANUSCRIPT
Venturello, Albert, Maina, & Ravizza, 1999; panic disorder: Barzega, Maina, Venturello, &
Bogetto, 2001; generalized anxiety disorder: Vesga-Lpez et al., 2008; posttraumatic stress
disorder: Tolin & Foa, 2006; depression: Parker & Brotchie, 2010) there is a paucity of
because several older epidemiological studies have found that SAD is more frequent in
women compared to men (e.g., Kessler et al., 1994). Although the gender literature for SAD
PT
is limited, it can offer meaningful information for both researchers and clinicians (Schneier &
RI
Goldmark, 2015). The goal of the present review is to systematically review the literature,
SC
identify studies reporting on gender differences in SAD, structure and integrate the findings,
present the findings clearly, and interpret the findings within the context of extant theories of
NU
both SAD and gender differences. Specifically, this paper will review gender differences in
comorbidity, course, treatment seeking, physiological arousal, and the oxytocin system.
Finally, an additional goal of this paper is to map different areas requiring further research.
D
Understanding gender differences in SAD can have implications for clinical assessment
E
and diagnosis, as well as for treatment delivery. For instance, information regarding gender
PT
differences in types of feared situations can guide and inform clinical assessment, as well as
CE
choice of exposure exercises for men and women. We believe that this review can contribute
to a more refined and gender-sensitive understanding of the disorder and can ultimately
AC
2.Literature Search
The literature search for the present review was conducted in a number of stages. First,
we searched the PubMed, PsycINFO, and the Cochrane Library databases using a number of
keywords to identify relevant studies. Key words included: social anxiety, gender,
differences, men, women, male, female, boys, girls. In the second stage, we reviewed the
4
ACCEPTED MANUSCRIPT
reference lists of relevant papers to identify additional sources that may have been missed in
our database search. In addition to peer reviewed publications, we reviewed book chapters on
gender differences in SAD (and their reference lists) to reduce the risk of biases in the peer
review process. In the fourth and final stage, we sent an e-mail to researchers in the field of
social anxiety disorder, requesting additional unpublished data on gender differences in order
PT
3. Gender Differences in Prevalence
RI
According to the DSM-5, prevalence of SAD is higher in women and this difference is
SC
more pronounced among adolescents (American Psychiatric Association, 2013). This
Epidemiologic Catchment Area study (ECA; Schneier, Johnson, Hornig, Liebowitz, &
MA
young adults aged 18-29 which found that compared to men, women are 1.5 times more
D
likely to meet diagnostic criteria for SAD; lifetime prevalence rates reported in that study
E
were 3.1% in women, compared to 2.0% in men. Data from the National Comorbidity Survey
PT
(NCS), with a sample of over 8,000 individuals aged 15-54, also indicated a higher lifetime
CE
prevalence rate of 15.5% for women, compared to 11.1% for men (Kessler et al., 1994).
Recently, a study based on data from the National Epidemiologic Survey on Alcohol and
AC
Related Conditions (NESARC) with a sample of 43,093 adults found similar results,
indicating that significantly more women suffer from SAD, with a lifetime prevalence of
4.2% for men, compared to 5.7% for women (Xu et al., 2012). In sum, despite differences in
epidemiological studies have shown that women are consistently found to have higher rates
5
ACCEPTED MANUSCRIPT
It is important to note that whereas the studies mentioned above demonstrated significant
gender differences in SAD prevalence, a study by Mclean, Asnaani, Litz, and Hofmann
(2011) reported divergent findings. These authors examined data from the Collaborative
mental health conducted among an overall of 20,013 adult (aged 18 and older) residents of
the United States (U.S.). The pattern of gender differences found was in contrast to those
PT
reported in previous studies; in fact, SAD was the only anxiety disorder that did not evidence
RI
significant gender differences in current or lifetime rates. However, it is important to note that
SC
these null findings were found using a Bonferroni correction accounting for 20 comparisons
(i.e., critical level for significance = 0.0025) and controlling for SES, education level, age,
NU
and race. Both Bonferroni correction and the practice of including multiple covariates in
regression analyses have been criticized for significantly reducing statistical power (e.g.,
MA
Perneger, 1998; Tabachnik & Fidell, 2013) suggesting that interpretation of these null
findings should be done with caution. Moreover, descriptive statistics were in the direction
D
indicating greater prevalence among women compared to men (lifetime prevalence for
E
Studies conducted outside the United States have demonstrated similar gender differences
CE
in SAD prevalence as found in the majority of epidemiological findings within the U.S. For
AC
example, results from a European study with a sample of 18,980 individuals (aged 15 or
older) from the United Kingdom, Germany, Italy, Spain, and Portugal indicated that
prevalence rates were found to be higher in women compared to men, with an odds ratio of
1.6 (Ohayon & Schatzberg, 2010). Similar findings were reported in a prospective
longitudinal study, which followed 591 young adults in Switzerland from the age of 18 to the
age of 35 (Merikangas, Avenevoli, Acharyya, Zhang, & Angst, 2002). In this study, women
exhibited higher lifetime prevalence rates of SAD, as well as higher sub-clinical levels of
6
ACCEPTED MANUSCRIPT
social anxiety compared to men. A community study conducted in France (Lpine &
Lellouch, 1995), with a sample of 1,787 participants aged 18 and above also found higher
lifetime prevalence rates of SAD in women compared to men (5.4% and 2.1% respectively).
Results from the Canadian Community Health Survey Cycle 1.2. (MacKenzie & Fowler,
2013) with a sample of 36,984 Canadians aged 15 or older indicated that women were 1.5
times more likely to meet diagnostic criteria for SAD. Another study conducted in Russia has
PT
also demonstrated a higher lifetime prevalence of SAD in women compared to men (Pakriev,
RI
Vasar, Aluoja, & Shlik, 2000).
SC
Studies conducted in East Asia have revealed similar patterns of gender differences in
SAD prevalence. A study conducted in Korea (Cho et al., 2007), with a sample of 6,275
NU
adults aged 18-64, demonstrated higher descriptive 12-month and lifetime prevalence rates in
MA
women compared to men (no inferential tests were reported). However, it is important to note
that prevalence in this sample was distinctly lower than that observed in Western samples
(e.g., 0.4% lifetime prevalence for women vs. 0.1% for men). This may be due to differences
E D
between individualistic and collectivistic cultures both in general (Oyserman & Lee, 2008)
PT
and in SAD specifically (Chang, 1997; Hofmann, Asnaani & Hinton, 2010; Schreier et al.,
2010). In addition, differences in stigma of mental disorders between countries and cultures
CE
can also contribute to the observed differences in prevalence (e.g., Griffiths et al., 2006;
AC
Ryder et al., 2008). Importantly, these explanations are by no means exhaustive, and many
Epidemiological Project; TPEP) gender differences in SAD prevalence were found (Hwu,
Yeh, & Chang, 1989). This study was based on three samples of 5,005, 3,004 and 2,995
participants aged 18 and above, selected from metropolitan Taipei, 2 small towns and 6 rural
villages in Taiwan, respectively. It was found that women in metropolitan Taipei had a higher
7
ACCEPTED MANUSCRIPT
lifetime prevalence of SAD compared to men in the same area (9.5% and 2.4% respectively).
Interestingly, this difference in prevalence was found only in the metropolitan area but not in
small towns and rural villages. In addition, it is important to note that the study was
conducted over 25 years ago and was based on DSM-III criteria. Additional studies in East
Asian countries are needed to draw firm conclusions regarding gender differences in SAD.
Finally, it is important to note that a review of 43 epidemiological studies from all around the
PT
world (Furmark, 2002), and a review of 21 epidemiological studies conducted in European
RI
countries (Fehm, Pelissolo, Furmark, & Wittchen, 2005) both concluded that women are
SC
more likely to have SAD compared to men.
(EDSP), with a sample of 3,021 German adolescents aged 14-25 years indicated a higher
lifetime prevalence rate of SAD in girls and women compared to boys and men (9.5% and
4.9% respectively; Wittchen et al., 1999). In addition, according to data from the National
E D
prevalent in girls compared to boys, with lifetime prevalence rates of 11.2% and 7%
respectively (Merikangas et al., 2010). Another study (Essau, Conradt, & Petermann, 1999)
CE
with a sample of 1,035 German adolescents aged 12-17 years indicated that girls were twice
AC
as likely to meet lifetime diagnostic criteria for SAD compared to boys (2.1% and 1%
respectively). Although the higher rates of SAD found in girls compared to boys are
consistent with previous findings, it is worth noting that the overall lifetime prevalence of
SAD in this study was distinctly lower than those observed in other samples of adolescents.
Finally, results from studies conducted in non-clinical samples of adolescents (e.g., La Greca
& Lopez, 1998; Ranta, Kaltiala-Heino, Koivisto, Tuomisto, Pelkonen, & Marttunen, 2007)
indicated that girls reported higher levels of social anxiety compared to boys.
8
ACCEPTED MANUSCRIPT
In sum, the literature consistently points to a higher prevalence rate of SAD in women
compared to men, and this difference may be greater among adolescents (see Table 1 for a
been replicated in studies conducted around the world (U.S., Europe, East Asia), and using
PT
4. Gender Differences in Clinical Presentation
RI
In this section we will review findings regarding gender differences in (1) clinical
SC
severity, (2) types of social situations feared, and (3) subjective distress.
NU
Clinical severity
MA
Turk et al. (1998) found that women who sought treatment for SAD reported greater
clinical severity compared to men on a number of symptoms measures (the Social Interaction
Anxiety Scale, Social Phobia Scale, the Fear Questionnaire Social Phobia subscale and the
E D
Liebowitz Social Anxiety Scale Performance Fear subscale). Moreover, in that study
PT
women reported greater fear and avoidance compared to men when constructing an
greater anxiety compared to men both in anticipation of and during a brief exposure. Another
AC
study based on data from the Australian National Survey of Mental Health and Well-being
(NSMHWB; Crome, Baillie, & Taylor, 2012), with a sample of 1,755 adults reporting at least
one social fear, demonstrated that women tended to report higher levels of social fear,
compared to men.
Similarly, a number of studies have demonstrated that women with SAD endorse a
greater number of social fears compared to men with SAD (Turk et al., 1998; Xu et al.,
9
ACCEPTED MANUSCRIPT
2012). For example, data from the National Comorbidity Survey Replication (NCS-R),
demonstrated that SAD involving 1-4 social fears is more common among men, whereas
SAD involving a larger number of fears is more common in women (Ruscio et al., 2008).
Finally, women with SAD were more likely to endorse a desire to die and a desire to
commit suicide compared to men with SAD. This finding was above and beyond the
PT
contribution of comorbid depression indicating that the difference cannot be attributed
womens greater likelihood to receive a diagnosis of major depressive disorder (Lpine &
RI
Lellouch, 1995). In sum, women with SAD report more severe symptoms, a greater number
SC
of social fears, as well as a greater desire to die and commit suicide, compared to men.
NU
Importantly, all the findings described in this section are based on self-report
methodology. Thus it remains unclear if women actually experience social anxiety more than
MA
men or simply report more social anxiety compared to men. Although a comprehensive and
definitive answer to this question is beyond the scope of the present review, we discuss
D
gender differences in physiological arousal (in section 9) as well as studies of reporting biases
E
in anxiety (in section 12) which converge to suggest that women may experience more
PT
anxiety above and beyond the possible effect of biased reporting. This topic is discussed in
CE
men and women with SAD. Specifically, women with SAD reported significantly greater fear
compared to men with SAD when interacting with authority figures, giving a talk in front of
an audience, working while being observed, entering a room when others are already seated,
group, and having a party. Men reported more fear compared to women when urinating in a
10
ACCEPTED MANUSCRIPT
public restroom and returning goods to a store (Turk et al., 1998). It is important to note that
men and women with SAD were found to experience similar fears in two domains: informal
social interactions (e.g., participating in small groups, going to a party) and being observed
(e.g., telephoning in public, eating in public). Interestingly, in contrast to the null findings
regarding gender differences in being observed (Turk, et al., 1998), a large community study
in Germany found that women with SAD were more likely to report fear of eating and
PT
drinking in public compared to men with SAD (Wittchen et al., 1999).
RI
An additional gender difference was reported by Flynn, Markway, and Pollard (1992)
SC
who asked individuals with SAD to rate their fear that other people would describe them
using 26 negative adjectives (e.g., weak, crazy). Compared to men with SAD, significantly
NU
more women with SAD feared other people would describe them as crazy, making no sense,
MA
Recent data from the epidemiologic sample of alcohol and related conditions
D
(NESARC) demonstrated that compared to men with SAD, women with SAD were more
E
figure, and speaking up in a meeting (Xu et al., 2012). They were also more likely to fear
CE
taking an important exam and eating and drinking in front of others. Men with SAD,
Taken together, the data suggest that women fear a wider range of social situations
compared to men; however, it is important to note that the studies documenting such
differences are about two decades old and no recent examinations have been made of such
gender differences. Given the significant changes observed in gender roles across the world
in the past decade (e.g., changes in employment, education patterns, and assumed family
roles for women and men; Cotter, Hersmen, & England, 2008; England, et al., 2004; Cotter,
11
ACCEPTED MANUSCRIPT
Hermsen, & Vanneman, 2011; Bolzendahl & Myers, 2004), it is possible that the types of
social situations that are feared by women versus men with social anxiety have also changed.
Future studies in the current cultural context of gender roles are needed in order to draw firm
conclusions regarding differences in the types of social situations feared by men and women.
Subjective distress
PT
Whereas previous data suggest that women have been found to report more fear
compared to men in a number of social situations and to have a greater number of social fears
RI
compared to men, there are some findings suggesting that men may experience more distress
SC
as a result of their social anxiety compared to women. For instance, in a longitudinal
NU
community study, men with sub-clinical SAD symptoms were found to report greater
subjective distress compared to women with sub-clinical SAD symptoms, suggesting that
MA
al., 2002).
D
Along these lines, despite the higher prevalence rate of SAD among women in the
E
PT
community (see section 3 above), it has been observed that men with SAD are as likely or
even more likely to seek treatment compared to women with the disorder (Weinstock., 1999),
CE
suggesting that distress or impairment for men may be greater. Patterns of treatment seeking
Men and women with SAD may have different patterns of impairment at work, and in
their social life. Regarding employment, studies have shown that compared to men with
SAD, fewer women with the disorder are employed (MacKenzie & Fowler, 2013) and among
those employed, men are more likely to be employed on a full time basis compared to women
12
ACCEPTED MANUSCRIPT
(Turk et al., 1998). Considering these findings it is not surprising that women with SAD
report having lower personal income compared to men with the disorder (MacKenzie &
Fowler, 2013).
These gender differences in employment may be related to the types of fears endorsed
by men and women (see section 4 above). Specifically, women have been shown to have
PT
greater fear of interacting with authority figures, giving a talk in front of an audience,
working while being observed, entering a room when others are already seated, and giving a
RI
report to a group all of which are common situations in work settings (Turk et al., 1998).
SC
This has led some researchers to suggest that men may have more exposure to work settings
and may thus develop greater comfort on the job compared to women (Turk et al., 1998).
NU
Alternatively, women may be less inclined to work or to work full time because of their
MA
work-related fears compared to men (Turk et al., 1998). As we noted previously, however,
employment patterns and exposure to work settings for women have significantly changed
over the past decades (e.g., Cotter, Hermsen, & England, 2008). Thus, it is important to
E D
conduct current examinations on this topic before firm conclusions can be drawn.
PT
In contrast to the findings described above, some studies have found that men have
CE
greater work impairment compared to women. For instance, an epidemiological study found
greater occupational impairment in men with SAD compared to women with the disorder
AC
(Lampel, Slade, Issakidis, & Andrews, 2003). However, other studies have found no gender
differences in work impairment. For instance, Merikangas and colleagues (2002) found that
along the course of their 15-year longitudinal study, occupational impairment was similar for
men and for women. Thus, findings on gender differences in work impairment remain
13
ACCEPTED MANUSCRIPT
Some studies have found that functioning and impairment in social life may differ
between men and women with SAD. Merikangas and colleagues (2002) found that men had
greater social impairment compared to women in their longitudinal study. Along these lines,
gender differences in relationship status and living arrangements among individuals with
SAD have been reported (MacKenzie & Fowler, 2013). Specifically, it was found that men
with SAD were more likely to report being single and living alone compared to women with
PT
SAD, whereas women with SAD were more likely to report being widowed, being separated,
RI
or divorced.
SC
In contrast to findings suggesting that men may have greater impairment in social life,
other studies have found the opposite pattern in which socially anxious women may be more
NU
socially impaired compared to socially anxious men. For instance, in a community survey,
MA
Cuming and Rapee (2010) reported that social anxiety was associated with diminished levels
of disclosure and openness in romantic relations and close friendships among women but not
among men. A similar pattern of results was also previously found in adolescents. For
E D
example, an older study with a sample of 250 high school students ranging from 10th to 12th
PT
grade (La Greca & Lopez, 1998) demonstrated that social anxiety (SA) was more strongly
linked to girls' social impairment compared to boys, such that girls with higher levels of SA
CE
reported fewer friendships and less intimacy, companionship, and support in their close
AC
relationships.
Other studies have found no differences between men and women with SAD in their
satisfaction of their relationships with their spouse, children, or friends (Yonkers, Dyck, &
Keller, 2001). Similarly, Sparrevohn and Rapee (2009) examined individuals with SAD and
expression, and intimacy in romantic relationships. In a study based on data from the
National Comorbidity Survey (NCS; Rodebaugh, Fernandez & Levinson, 2012), it was found
14
ACCEPTED MANUSCRIPT
that SAD had a negative effect on friendship quality in both men and women. Whereas in
men this negative effect was exacerbated when comorbid with generalized anxiety disorder,
equivocal findings. Currently, opposing findings preclude us from making reliable inferences
PT
on gender differences in functioning and impairment and future research is needed to shed
RI
6. Gender Differences in Comorbidity
SC
Data from the national epidemiologic sample on alcohol and related conditions
NU
(NESARC) has indicated that whereas men with SAD are more likely to suffer from a
comorbid externalizing disorder, women with SAD are more likely to suffer from comorbid
MA
internalizing disorders (Xu et al., 2012). Specifically, compared to women with SAD, men
with SAD were more likely to suffer from lifetime alcohol abuse and dependence,
D
pathological gambling, conduct disorder, and antisocial personality disorder. Women with
E
PT
SAD, on the other hand, were more likely to suffer from all mood and anxiety disorders, with
the exception of bipolar disorder (for which no gender differences were found). Similarly,
CE
findings from a study based on the Canadian Community Health Survey Cycle 1.2 (CCSH),
indicated that women with SAD were more likely to meet criteria for either comorbid lifetime
AC
or 12-month major depressive disorder (MDD) compared to men with SAD (MacKenzie &
Fowler, 2013). Finally, data from a large prospective longitudinal study of adolescents and
young adults (Early Developmental Stages of Psychopathology Study; Beesdo et al., 2007),
indicated that girls with SAD have an increased risk for developing subsequent MDD
compared to boys.
15
ACCEPTED MANUSCRIPT
Turk and colleagues (1998) examined 212 treatment-seeking individuals with SAD and found
that 38.4% of men and 48.5% of women received a comorbid diagnosis of an additional
anxiety disorder and 47.9% of men and 56.1% of women received a diagnosis of any mood or
anxiety disorder. Thus, in that study, women with SAD were more likely than men with SAD
to receive comorbid diagnoses of additional anxiety and mood disorders. Importantly, these
PT
differences were not statistically significant, but were in the direction of previous findings
RI
described above. Similarly, in an 8-year prospective longitudinal study (Yonkers et al., 2001),
SC
women with SAD were found to have more comorbid agoraphobia compared to men,
whereas men with SAD were found to have more comorbid substance use disorders
NU
compared to women. In an adolescent sample, SAD was associated with cigarette smoking
among boys, but was negatively associated with drug use among girls (Wu et al., 2010).
MA
Finally, in a study with a sample of 174 cannabis users (Buckner, Zvolensky, & Schmidt,
2012) it was found that among men, social anxiety was positively related to the number of
D
It is important to note that not all studies find this pattern of comorbidity. Specifically,
CE
some studies have reported a different pattern of comorbidity regarding depression. For
AC
example, results from an older community study indicated that men with SAD were more
likely to have a lifetime major depressive episode compared to women with SAD an
opposite pattern to the one described above (Lpine & Lellouch, 1995). Similarly, a more
recent prospective longitudinal study of adolescents (Vnnen et al., 2011) found that only
for boys, SAD at baseline increased the risk for depression over the next two years, whereas
among girls, baseline depression was a risk factor for subsequent SAD. In addition, other
studies have found divergent results regarding alcohol use disorders (AUD). For example, a
16
ACCEPTED MANUSCRIPT
study based on data from the National Comorbidity Survey (NCS; Kessler et al., 1997)
demonstrated that women with SAD exhibit significantly higher rates of both alcohol abuse
and dependence than men with the disorder. Following this, a 3-year prospective study with a
sample of 1803 young adults similarly demonstrated that only among women, SAD was a
risk factor for development of alcohol use disorders (Buckner & Turner, 2009).
PT
Finally, it is important to note that some gender differences in comorbidity may not be
specific to SAD but are rather shared with other anxiety disorders. For instance, Mclean et al.
RI
(2011) examined gender differences in anxiety disorders, and found that compared to men,
SC
women with a lifetime diagnosis of any anxiety disorder were more likely to be diagnosed
with another anxiety disorder, with MDD and with bulimia nervosa. Women were less likely
NU
than men to be diagnosed with a substance use disorder, ADHD, or intermittent explosive
MA
similar pattern of gender differences in comorbidity such that women were more likely to
have depression comorbid with anxiety, whereas men were more likely to meet criteria for
E D
comorbid lifetime alcohol and substance use disorders (e.g., Kessler et al., 1997; Breslau,
PT
Schultz & Peterson, 1995; Marcus et al., 2005). However, some gender differences in SAD
are unique to the disorder. Specifically, findings from a study based on more recent data from
CE
the from the National Comorbidity Survey-Replication (NCS-R), indicated that even after
AC
controlling for depression, SAD predicted suicidal ideation and suicide attempts among
women, but not among men (Cougle, Keough, Riccardi, & Sachs-Ericsson, 2009). Thus,
these findings suggest a gender difference in comorbid suicidality which is specific to SAD,
17
ACCEPTED MANUSCRIPT
In the present section we will review findings on potential gender differences in the
course of SAD and specifically in (1) age of onset; (2) chronicity and persistence; and (3)
A number of studies have examined whether age of onset of SAD is different for men and
PT
women. Previous data from the Epidemiologic Catchment Area (ECA) study indicates no
significant difference in age of onset of SAD among men and women (Schneier et al., 1992).
RI
In more current data, there were similar findings with no significant gender difference in age
SC
of onset of SAD being found in the CPES (Mclean et al., 2011). In a longitudinal study based
NU
on data from the Harvard/Brown Anxiety Research Program, no gender differences in age of
onset were found, with women reporting a mean age of onset of 14.2 years and men reporting
MA
a mean age of onset of 14.4 years (Yonkers et al., 2001). Finally, in a large (n = 3,021) 4-
wave longitudinal study in Germany, no overall differences in age of onset distributions were
D
found between men and women (Beesdo et al., 2007). However, in this study it was found
E
that after the age of 20, men may experience a larger decrease in incidence of SAD compared
PT
to women (Beesdo et al., 2007). Thus, no consistent gender differences in age of onset have
CE
been found. Interestingly, advanced puberty was found to be associated with increased SA
symptoms for girls but not for boys, suggesting that despite the similarity in age of onset,
AC
different processes may lead to onset among girls and boys (Deardorff et al., 2007). Future
Few studies have focused on chronicity and persistence of SAD within the context of
differences in the percentage of women and men who experienced a remission after one year,
four years, and eight years of prospective follow up (with 38% for women and 32% for men
18
ACCEPTED MANUSCRIPT
during the eight-year period). However, the researchers found that SAD had a more chronic
course among women who had low Global Assessment of Functioning (GAF) scores and a
history of suicide attempts at baseline compared to men who had the same characteristics.
Similar results were reported in a follow up study which included additional participants
(Yonkers, Bruce, Dyck, & Keller, 2003). In that study, it was found that remission and
relapse rates did not significantly differ between men and women with SAD. It is important
PT
to note that currently there is limited data examining gender differences in this domain.
RI
Future studies are needed to increase our confidence in these findings.
SC
Finally, a large study (n = 12,792) with a representative sample of older adults from
Canada found that significant differences in prevalence which exist among younger
NU
individuals (i.e., women being more likely to have SAD) are reduced in older age (Cairney,
MA
McCabe, Veldhuizen, Streiner, & Herrmann, 2007). Specifically, among individuals over 54
years of age, no differences were found in prevalence rates between men and women. This
mirrors findings from the depression literature showing that similar gender differences in
E D
prevalence rates in depression (i.e., women being more likely to have depression) disappear
PT
among older adults (Bebbington et al., 1998). However, it is also important to consider that
these reduced gender differences in SAD prevalence may not be the result of aging, but rather
CE
of possible cohort effects. Supporting this explanation, cohort effects in SAD prevalence have
AC
been found in epidemiological data collected in the US (Heimberg, Stein, Hiripi, & Kessler,
2000).
Thus, the age of onset and chronicity of SAD seem to be similar for men and women, but
gender differences may be more prominent among younger individuals with SAD compared
to older individuals. The reasons behind this phenomenon are not sufficiently understood and
additional research is needed to elucidate the reasons behind this differing lifetime trajectory
of SAD.
19
ACCEPTED MANUSCRIPT
According to the DSM-5, whereas women are more likely to have SAD, men with the
disorder are more likely to seek treatment (American Psychiatric Association, 3102). This is
especially interesting given that women have been found to seek treatment more than men for
other disorders (e.g., Shear, Feske, & Greeno, 2000, for anxiety disorders in general; Vesga-
PT
Lpez et al., 2008, for generalized anxiety disorder; Goodwin, Koenen, Hellman, Guardino,
& Struening, 2002, for obsessive-compulsive disorder; Gater et al., 1998, for panic disorder).
RI
Thus, SAD may be unique among the anxiety disorders in patterns of treatment seeking
SC
among men and women. Similarly, in a recent review, the authors noted that compared to
other anxiety disorders, men are over-represented among patients seeking treatment for SAD
NU
(Schneier & Goldmark, 2015).
MA
Data from several decades ago have indicated that a greater number of men were referred
to treatment for social anxiety symptoms at a university clinic (Amies, Gelder & Shaw,
1983). It was also found that compared to other anxiety disorders, fewer women with SAD
E D
were referred to and participated in behavioral treatment (Solyom, Ledwidge & Solyom,
PT
1986). Higher rates of help seeking in men with SAD compared to women have also been
documented in the past, with more men with the disorder reported having consulted with a
CE
psychiatrist during the past year versus women with SAD (8.3% and 5.8% respectively;
AC
Lpine & Lellouch, 1995). However it is important to note that in that study participants were
not specifically asked whether the consultation was due to SAD symptoms.
Later studies have found equal proportions of men and women with SAD in treatment
settings. These findings still indicate a greater propensity of men to seek treatment as SAD
has a higher prevalence rate among women. For example, in a previous review of 35
cognitive behavioral treatment (CBT) studies for SAD, which included 1,514 patients , an
equal gender proportion was demonstrated, such that 52% of patients were women and 48%
20
ACCEPTED MANUSCRIPT
were men (Heimberg & Juster, 1995). More recently, equal proportions of men and women
seeking treatment for SAD have also been demonstrated in naturalistic settings1. One
example is an open trial which examined CBT for SAD (Aderka, Hermesh, Marom,
Weizman & Gilboa-Schechtman, 2011). In that study, there was no significant difference
between the number of men and women seeking treatment (47% women, 53% men). Along
these lines, Marom, Gilboa-Schechtman, Aderka, Weizman, and Hermesh (2009) reported
PT
equal proportions of men and women with generalized SAD seeking cognitive behavioral
RI
group therapy (CBGT) for the disorder in a naturalistic setting (54% women and 46% men).
SC
Interestingly, in that study a different pattern emerged in patients who did not meet criteria
for the generalized subtype of SAD according to the DSM-IV (i.e., patients who had SAD
NU
which was associated with a small number of social situations). Specifically, among these
patients there was a smaller proportion of women seeking treatment compared to men (38%
MA
vs. 62% respectively; Marom et al., 2009). This is consistent with the finding that men with
low or sub-clinical levels of SAD symptoms have been found to report greater distress
D
and related conditions (Xu et al., 2012). In that study, women and men with lifetime SAD did
CE
not differ significantly in the reported probability of treatment-seeking, with the exception
AC
that women were more likely to have received pharmacological treatment for SAD compared
to men. Importantly, these findings should be considered in light of the fact that men in the
sample were significantly more likely to use alcohol (24.8%) and drugs (7.25%) to relieve
1
We focused our review on naturalistic settings (as opposed to randomized controlled trials) as researchers
may stratify the randomization procedure to provide equal rates of men and women. We were primarily
interested in naturalistic settings as they may provide a more accurate assessment of patient treatment
seeking behavior in the population.
21
ACCEPTED MANUSCRIPT
possible that mens increased alcohol and drug use served as a form of self-medication which
In sum, few studies have directly examined gender differences in treatment seeking
for SAD. However, data from treatment settings and open trials demonstrate equal
proportions of men and women seeking treatment for SAD. Interestingly, the equivalent
proportions of men and women among treatment seekers may in fact point to an important
PT
gender difference when considered in light of gender differences in prevalence. Specifically,
RI
despite the higher prevalence of SAD among women, men may be more likely to seek
SC
treatment, thus resulting in similar proportions of men and women in treatment studies (and
especially in non-stratified open trials). Importantly, considering that some of the data
NU
presented in this section is a few decades old, and some inconsistencies were found in the
literature, future studies directly examining gender differences in treatment seeking are much
MA
needed in order to draw firm conclusions regarding treatment seeking patterns in men and
Physiological symptoms and arousal play a central role in the maintenance of SAD (e.g.,
CE
Clark, 2001). Interestingly, only a few studies examined gender differences in physiology
One study examined older individuals with SAD and their physiological responses to
a socially threatening situation (i.e., giving a speech; Grossman, Wilhelm, Kawachi, &
Sparrow, 2001). It was found that although both men and women with SAD reported more
women with SAD were hyper-responsive to the stressor in comparison to control subjects, as
indicated by measures of heart rate (HR), blood pressure, cardiac output, and systemic
22
ACCEPTED MANUSCRIPT
vascular resistance. Consistently, a recent study found that women with SAD had higher HR
at rest and lower heart rate variability (HRV) compared to non-socially-anxious women
(Alvares et al., 2013). Importantly, these differences were not observed among men (Alvares
et al., 2013). The authors suggested that these findings reflect an enhanced sensitivity to the
PT
Findings from a study conducted in a non-clinical sample are in line with those
described above (Shimizu, Seery, Weisbuch, & Lupien, 2011). In that study, participants
RI
engaged in an interaction while physiological measures were recorded. It was found that
SC
among women (but not men), those higher in SA exhibited cardiovascular responses
consistent with greater threat (e.g., higher total peripheral resistance and lower cardiac
NU
output) compared to those lower in SA.
MA
One study examined gender differences in endocrinal activity among individuals high
and low on SA (Maner, Miller, Schmidt & Eckel, 2008). In that study, participants were
D
randomly assigned to either win or lose a rigged face-to-face competition with a same-gender
E
anxious men, but not in non-socially-anxious men nor in women. According to the authors,
CE
these results are consistent with evolutionary perspectives suggesting that men have more to
gain from achieving dominance compared to women, and that men therefore tend to be more
AC
concerned with their level of dominance. Thus, social anxiety may be linked more strongly
SAD are scarce. However, findings show that compared to their same-sex, non-anxious
autonomic parameters and cardiovascular responses, whereas men with SAD evidence
23
ACCEPTED MANUSCRIPT
reductions in testosterone following defeat. Although findings are still preliminary and many
future studies are needed in order to draw firm conclusions, these findings suggest that
physiological processes in SAD may be different among men and women, and these
PT
During recent years, the neuropeptide oxytocin (OXT) has received substantial
empirical attention and has been found to play a role in SAD as well as other disorders (see
RI
reviews by Heinrichs, von Dawans, & Domes, 2009; Kirsch, 2015; Marazziti, Abelli, Baroni,
SC
Carpita, Ramacciotti, DellOsso, 2015; Meyer-Lindenberg, Domes, Kirsch, & Heinrichs,
NU
2011; Neuman & Slattery, 2016; & van Honk, Bos, Terburg, Heany, & Stein, 2015).
Specifically, OXT has been found to have anxiolytic effects as well as social effects (e.g.,
MA
effects on approach/avoidance tendencies, social cognition) which may be highly relevant for
SAD (Heinrichs et al., 2009; Kirsch, 2015; Marazziti et al., 2015; Meyer-Lindenberg et al.,
D
2011; Neuman & Slattery, 2016; van Honk et al., 2015). Despite the large body of work on
E
OXT in SAD, very little is known about gender differences in this system among individuals
PT
Most studies of individuals with SAD have included only male participants. This is
due to the effects of OXT on uterus contraction which may result in premature delivery, and
AC
due to its interaction with the menstrual cycle which can affect plasma levels of OXT (e.g.,
Meyer-Lindenberg et al., 2011; Born et al., 2002). These health risks and potential
examinations of OXT. Specifically, exclusively male samples were used to examine OXT
24
ACCEPTED MANUSCRIPT
2014), interaction of OXT with attachment among individuals with SAD (Fang et al., 2014),
OXT enhancement of functional connectivity between the amygdala and the bilateral insula
and middle cingulate/dorsal anterior cingulate gyrus among individuals with SAD (Gorka et
al., 2015), cognitive-behavior treatment of college students with SAD (Guastella et al., 2009),
OXT attenuation of heightened amygdala reactivity to fearful faces among individuals with
SAD (Labuschagne et al., 2010), and OXT attenuation of heightened activation in the medial
PT
prefrontal cortex extending into anterior cingulate cortex among individuals with SAD
RI
(Labuschagne et al., 2012). Importantly, as these studies included only male participants, our
SC
ability to draw conclusions regarding gender differences is very limited.
A few studies have examined OXT in SAD using mixed-gender samples. Hoge and
NU
colleagues (2008) examined 10 females and 14 males with SAD and compared them to non-
MA
anxious controls. Findings indicated no differences in plasma levels of OXT between males
and females. In addition, gender was used as a control variable (covariate) in all between-
groups analyses, precluding the ability to draw conclusions regarding gender differences.
E D
Similarly, Hoge and colleagues (2012) examined 32 males and 6 females with SAD and
PT
compared them to non-anxious controls in plasma levels of OXT. However, due to the small
sample size of females with SAD, the difference in sample size between males and females
CE
with SAD, and the lack of information regarding stage of the menstrual cycle, gender
AC
differences were not examined and gender was controlled in all analyses. Tabak and
colleagues (2016) examined the CD38 gene (which regulates secretion of OXT) and its
interaction with chronic interpersonal stress in predicting social anxiety among male and
female adolescents. However, no gender effects were examined and gender was included as a
covariate in all analyses. Finally, Ziegler and colleagues (2015) examined the receptor for
OXT (OXTR) and its methylation (a process which affects gene expression) in a large mixed-
25
ACCEPTED MANUSCRIPT
gender sample of individuals with (n = 110) and without SAD (n = 110). No gender effects
Albeit beyond the scope of the present review, it is important to note that gender
differences in the OXT system have been found in healthy (non-anxious) individuals (e.g.,
Fischer-Shofty, Levkovitz, & Shamay-Tsoory, 2013; also see Wigton et al., 2015 for gender
PT
differences found in a meta-analysis) and gender differences in OXT among healthy
individuals were found to be associated with trait anxiety (e.g., Weisman et al., 2013). Thus,
RI
future studies specifically examining gender differences in the OXT system in SAD are
SC
greatly needed and some researchers have suggested examining postmenopausal women, and
women in different stages of the menstrual cycle to achieve this goal (Meyer-Lindenberg et
NU
al., 2011). Future studies should also address methodological differences in OXT
MA
measurement (e.g., using vs. not using extraction) which have complicated the interpretation
and comparison of results of many previous studies in the literature (see McCullough,
Findings from the present review indicate that women are more likely to have SAD.
CE
This gender difference in prevalence is greatest among adolescents and seems to diminish
along the course of life. In addition to having greater prevalence, women also report greater
AC
clinical severity as indicated by more severe symptoms, higher levels of social fears, and a
greater number of social fears. Physiological findings support these differences in self-
reported data as demonstrated by higher levels of arousal in women with SAD (but not in
men with SAD) compared to their same-sex non-anxious counterparts. Interestingly, whereas
women are more likely to suffer from SAD and demonstrate greater clinical severity, men
26
ACCEPTED MANUSCRIPT
with the disorder may seek treatment to a greater extent. Along these lines, some findings
suggest that men may experience more distress as a result of their SA compared to women.
According to the present review, the course of SAD seems to be similar for men and
women, such that studies find no gender difference in age of onset and in the chronicity of the
disorder. In addition, the present review of the literature found inconclusive findings
PT
regarding gender differences in functional impairment, and future research is much needed in
order to shed light on this issue. Findings regarding gender differences in patterns of
RI
comorbidity were also divergent and require additional research. Specifically, whereas some
SC
studies demonstrate that men with SAD are more likely to suffer from a comorbid
externalizing disorder and women with SAD are more likely to suffer from a comorbid
NU
internalizing disorder, other studies report an opposite pattern of comorbidity.
MA
Overall, the present review found important gender differences in several domains of
SAD. Broadening and deepening our knowledge and awareness of these gender differences
D
can facilitate more sensitive and specific treatment for men and women with SAD. In the last
E
section of this review we will attempt to frame the gender differences reported within the
PT
12. Discussion
AC
The findings of the present review can be understood in the context of several gender-
related theories. However, it is important to note that much more research needs to be
conducted (e.g., directly juxtaposing predictions from competing theories) before we can
firmly attribute our findings to processes described in a certain theory but not others. Thus,
our goal is to suggest possible interpretations of the findings, while acknowledging the
limitations of the current knowledge in the literature. We will focus on the two main findings
of the present review: (1) that women report more social anxiety and are diagnosed with SAD
27
ACCEPTED MANUSCRIPT
to a greater extent than men, and (2) that men may seek treatment to a greater extent than
women. In addition, we discuss reporting bias and its potential influence on the findings of
this review.
The current review found a higher prevalence of SAD in women as well as elevated
PT
clinical severity in women compared to men. A possible explanation for this finding can be
derived from self-construal theory (Cross & Madson, 1997; Cross, Hardin, & Gercek-Swing,
RI
2011). According to this theory, men and women construe themselves differently: men tend
SC
to construct and maintain an independent self-construal in which others are represented as
NU
separate from the self, whereas women tend to construct and maintain an interdependent self-
construal, in which others are represented as part of the self (Markus & Kityama, 1991).
MA
Thus, according to this theory, womens sense of self is derived from their relationships with
significant others to a greater extent compared to men. Importantly, this does not mean that
D
all women are highly interdependent and all men are highly independent, but rather, that
E
gender differences are found on average between men and women in self-construals. Self-
PT
construal theory has received ample empirical support (see Cross et al., 2011, for a
CE
comprehensive review). For instance, in a recent series of studies with over 1200 participants,
women were found to define themselves as higher in relational interdependence and men
AC
higher in agency and independence (Guimond, Chatard, Martinot, Crisp, & Redersdorff,
greater extent compared to men. Specifically, women were found to experience greater
reductions in daily life satisfaction compared to men when they felt misunderstood in
interpersonal interactions (Lun, Kesebir, & Oishi, 2008). Similarly, womens reports of
positive and negative affect were predicted by relationship harmony, whereas mens reports
28
ACCEPTED MANUSCRIPT
women in social situations that might include scrutiny, negative evaluation, and potential
rejection by others. Put differently, because women may construe their self as being
interdependent to a greater extent than men, and may be more reactive to the status of their
relationships with others, they may experience more anxiety regarding the consequences of
PT
construals, women fear more types of social situations, report higher levels of fear and
RI
anxiety symptoms, and ultimately have higher rates of SAD compared to men.
SC
The second main finding of the present review is that men with SAD may have higher
rates of treatment seeking compared to women with the disorder. This can be understood in
NU
the context of self-discrepancy theory (SDT; Higgins, 1987, 1996) and Identity-Discrepancy
MA
Theory (IDT; Large & Marcussen, 2000; Marcussen & Large, 2003). According to SDT,
individuals have an actual self (i.e., traits the individual perceives having), an ideal self (i.e.,
traits the individual wishes for), and an ought self (i.e., traits the individual perceives that
E D
he or she should have). According to SDT, discrepancies between the actual self on one hand
PT
and the ideal or ought self on the other, create distress. IDT extends the ideas presented by
SDT by suggesting that each individual has multiple selves (or multiple roles) for which
CE
discrepancies between actual and ideal/ought selves may occur. Moreover, some situations
AC
may activate a certain role with an associated discrepancy (e.g., between actual and ideal
selves) and result in distress, whereas other situations may activate roles with no discrepancy
When examining our findings through the lens of IDT and SDT, it is possible that
mens greater propensity to seek treatment for SAD may stem from greater identity
discrepancy. As traditional social roles (or gender stereotypes) depict mens ideal or ought
selves as assertive, dominant, and active (Eagly and Wood, 1991; Eagly, Wood, & Diekman,
29
ACCEPTED MANUSCRIPT
2000), men might experience a greater discrepancy between their actual and ideal/ought
selves as a result of SAD. This in turn can be interpreted and labeled by men themselves
and/or by their environment as being more of a problem compared to women, for whom
traditional social roles (or gender stereotypes) and SAD are not as conflicting as they are for
men and do not create a large discrepancy. Thus, it is possible that women have higher rates
of SAD and greater symptom severity, but because the disorder creates less of a discrepancy
PT
with their ought or ideal social roles it may not lead them to seek treatment as much as men.
RI
A number of empirical studies provide data consistent with the self-discrepancy
SC
explanation. Roberts, Hart, Coroiu, and Heimberg (2011) compared treatment-seekers with
SAD and non-anxious controls and found that discrepancy between actual and ideal
NU
instrumentality or agency (i.e., traditional male social role) was greater among treatment
MA
seekers with SAD compared to non-anxious controls. Moscovitch, Hofmann, and Litz (2005)
examined undergraduate students and found significant interactions between gender and
Specifically, among men, interdependence was positively associated with social anxiety,
PT
whereas for women interdependence was negatively associated with social anxiety.
Moreover, among men independence was negatively associated with social anxiety whereas
CE
among women independence was positively associated with social anxiety. This suggests that
AC
social anxiety may be exacerbated as discrepancy increases. However, despite the empirical
support cited above, it is important to note that direct examinations of self-discrepancy theory
in SAD have been rare and viewing treatment-seeking in light of self-discrepancy theory
remains speculative. Future research can provide additional tests of the theory in SAD and
In sum, it is possible that women experience more social anxiety due to a greater
interdependent self-construal compared to men. However, social anxiety may create a larger
30
ACCEPTED MANUSCRIPT
discrepancy between actual and ideal or ought selves for men compared to women due to
gender stereotypes and traditional social roles. Specifically, for men social anxiety might
evoke more self-criticism as well as more judgment and negative reactions from the
environment, thus enhancing the need and the urgency in seeking help. Importantly, these
explanations remain speculative due to the paucity of empirical studies on this topic. Future
studies can help clarify these issues and are needed before firm conclusions can be drawn.
PT
Reporting bias and its possible role
RI
An important alternative explanation for the findings that women report more social
SC
anxiety and are diagnosed with SAD more than men is that they are primarily the result of
NU
gender differences in reporting anxiety, rather than gender differences in the experience of
anxiety. This explanation can be viewed as consistent with the theories described above as for
MA
discrepancy between actual and ought/ideal selves. However, empirical findings do not
D
provide support for this explanation. Research on gender differences in physiological arousal
E
has consistently found heightened arousal in women but not in men, and this gender
PT
difference in arousal mirrors that found using self-report measures. This convergence in
CE
findings using different measurements each with its own unique measurement error, increases
our confidence that results cannot be attributed to reporting bias alone as reporting bias
AC
Along these lines, recent experimental studies have failed to find support for
underreporting of anxiety among men (McLean & Hope, 2010; Stoyanova & Hope, 2012). In
both of these studies, participants took part in an anxiety-provoking task. Half of the
participants were connected to sham physiological equipment and told that the physiological
measures would verify their true level of anxiety. The other half were similarly connected
31
ACCEPTED MANUSCRIPT
but were told the measurement is irrelevant to the current experiment. The assumption in both
studies was that being connected to a device participants perceived as a lie detector would
reduce reporting bias. No differences in reporting of anxiety were found between the two
conditions, but as expected women reported greater anxiety and evidenced greater avoidance
compared to men.
PT
An additional factor that may possibly contribute to differences between men and
RI
Put differently, because men and women may interpret questions regarding their anxiety
SC
differently, the same questions may be measuring different constructs in men and women.
Future studies can examine differential item functioning (DIF; Osterlind & Everson, 2009) in
NU
men and women to shed light on this issue.
MA
observed gender differences, some empirical evidence suggests this effect may not be
D
pronounced. Importantly, much more research needs to be conducted in order to draw firm
E
highlighted areas requiring further research, and believe that continued research and
integration of scientific findings with existing theories is essential in order to increase our
understanding of gender differences. This includes updated epidemiological data that is likely
to better reflect current employment and social patterns, to elucidate how SAD currently
that may differ between men and women during the experience of SA stressors and situations
32
ACCEPTED MANUSCRIPT
would be useful. Such studies would enhance our understanding of gender differences in
SAD, which can in turn help us to develop more gender-sensitive and tailored interventions
For instance, in the context of CBT, our findings on gender differences in prevalence and
PT
their gender and normalize their experience (e.g., SAD is very common among women for
female clients; Whereas SAD is common among women, some data suggest that men seek
RI
treatment to a greater extent for male clients). Moreover, data regarding gender differences
SC
in feared situations can help tailor exposures specifically for men and women. Finally, data
on gender differences in physiological arousal may inform the use of relaxation strategies in
NU
treatment (e.g., more for female clients). Although all such gender-informed adaptations
MA
require future research before being widely implemented, they may provide avenues for
Future research on gender differences in SAD should also address issues of differing
E
sexual orientations and individuals who identify as gender non-conforming. Many of the
PT
current SAD measures rely on a predominantly heterosexual orientation (e.g., measuring fear
CE
homosexual), and the lens we use to interpret current findings relies on more traditional
AC
gender roles for men and women. The empirical data on LGBTQ and gender non-conforming
investigating differences in SAD based on gender will likely have to consider how such
factors influence current knowledge and how to incorporate these variables in future research
in an inclusive way.
33
ACCEPTED MANUSCRIPT
Maya Asher was funded by the Advanced Studies Scholarship of the University of Haifa. The
Advanced Studies Authority had no role in the preparation of this manuscript. Idan M.
Aderka was funded by the University of Haifa. The University had no role in the preparation
of this manuscript. Anu Asnaani was funded by the University of Pennsylvania. The
University had no role in the preparation of this manuscript.
Contributors
Maya Asher conducted the literature review and contributed to the writing and structure of
the manuscript. Idan M. Aderka and Anu Asnaani contributed to the writing and the structure
PT
of the review.
Conflict of Interest
RI
The Authors declare they have no conflicts of interest.
SC
NU
MA
E D
PT
CE
AC
34
ACCEPTED MANUSCRIPT
References
Aderka, I. M., Hermesh, H., Marom, S., Weizman, A., & Gilboa-Schechtman, E. (2011).
Cognitive behavior therapy for social phobia in large groups. International Journal of
Aderka, I. M., Hofmann, S. G., Nickerson, A., Hermesh, H., Gilboa-Schechtman, E., &
PT
Marom, S. (2012). Functional impairment in social anxiety disorder. Journal of Anxiety
RI
SC
Alden, L. E., & Taylor, C. T. (2004). Interpersonal processes in social phobia. Clinical
Alonso, J., Angermeyer, M. C., Bernert, S., Bruffaerts, R., Brugha, T. S., Bryson, H., &
PT
Vollebergh ,W. A. M. (2004). Disability and quality of life impact of mental disorders in
CE
Europe: Results from the European Study of the Epidemiology of Mental Disorders
0047.2004.00325.x
Alvares, G. A., Quintana, D. S., Kemp, A. H., Van Zwieten, A., Balleine, B. W., Hickie,
I. B., & Guastella, A. J. (2013). Reduced heart rate variability in social anxiety disorder:
35
ACCEPTED MANUSCRIPT
Amies, P. L., Gelder, M. G., & Shaw, P. M. (1983). Social phobia: a comparative clinical
Barzega, G., Maina, G., Venturello, S., & Bogetto, F. (2001). Gender-related distribution
PT
Bebbington, P. E., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., & Meltzer,
H. (1998). The influence of age and sex on the prevalence of depressive conditions: report
RI
from the National Survey of Psychiatric Morbidity. Psychological medicine, 28(01), 9-19.
SC
Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Hfler, M., Lieb, R., & Wittchen, H. U.
NU
(2007). Incidence of social anxiety disorder and the consistent risk for secondary
depression in the first three decades of life. Archives of General Psychiatry, 64(8), 903-
MA
912.
D
Bogetto, F., Venturello, S., Albert, U., Maina, G., & Ravizza, L. (1999). Gender-related
CE
441.
AC
Bolzendahl, C. I., & Myers, D. J. (2004). Feminist attitudes and support for gender
equality: Opinion change in women and men, 19741998. Social Forces, 83(2), 759-789.
Buckner, J. D., & Turner, R. J. (2009). Social anxiety disorder as a risk factor for alcohol
use disorders: A prospective examination of parental and peer influences. Drug and
36
ACCEPTED MANUSCRIPT
and social anxiety: The roles of gender and cannabis use motives. Addictive
Breslau, N., Schultz, L., & Peterson, E. (1995). Sex differences in depression: a role for
PT
Cairney, J., McCabe, L., Veldhuizen, S., Corna, L. M., Streiner, D., & Herrmann, N.
(2007). Epidemiology of social phobia in later life. The American journal of geriatric
RI
psychiatry, 15(3), 224-233.
SC
Chang, S. C. (1997). Social anxiety (phobia) and east Asian culture. Depression and
NU
Anxiety, 5, 115-120. doi:10.1002/(SICI)1520-6394(1997)5:3<115::AID-DA1>3.0.CO;2D
MA
Cho, M. J., Kim, J. K., Jeon, H. J., Suh, T., Chung, I. W., Hong, J. P., ... & Hahm, B.G.
Korean adults. The Journal of nervous and mental disease, 195(3), 203-210.
E
interventions relating to the self and shyness. (pp. 259-279): New York, NY: John Wiley
& Sons.
AC
Clark-Elford, R., Nathan, P. J., Auyeung, B., Mogg, K., Bradley, B. P., Sule, A., ... &
Neuropsychopharmacology, pyu012.
Cotter, D., England, P., & Hermsen, J. (2008). Moms and jobs: Trends in mothers
employment and which mothers stay home. Families as they really are, 416-24.
37
ACCEPTED MANUSCRIPT
Cotter, D., Hermsen, J. M., & Vanneman, R. (2011). The End of the Gender Revolution?
Gender Role Attitudes from 1977 to 20081. American Journal of Sociology, 117(1), 259-
289.
Cougle, J. R., Keough, M. E., Riccardi, C. J., & Sachs-Ericsson, N. (2009). Anxiety
PT
psychiatric research, 43(9), 825-829.
Crome, E., Baillie, A., & Taylor, A. (2012). Are male and female responses to social
RI
phobia diagnostic criteria comparable? International journal of methods in psychiatric
SC
research, 21(3), 222-231. NU
Cross, S. E., & Hardin, E. E. Gercek-Swing, B.(2011). The what, how, why, and where of
Cross, S. E., & Madson, L. (1997). Models of the self: self-construals and gender.
D
Cuming, S., & Rapee, R. M. (2010). Social anxiety and self-protective communication
PT
Deardorff, J., Hayward, C., Wilson, K. A., Bryson, S., Hammer, L. D., & Agras, S.
(2007). Puberty and gender interact to predict social anxiety symptoms in early
AC
Dodhia, S., Hosanagar, A., Fitzgerald, D. A., Labuschagne, I., Wood, A. G., Nathan, P. J.,
38
ACCEPTED MANUSCRIPT
Eagly, A. H., & Wood, W. (1991). Explaining sex differences in social behavior: A meta-
Eagly, A. H., Wood, W., & Diekman, A. B. (2000). Social role theory of sex differences
PT
England, P., Allison, P., Li, S., Mark, N., Thompson, J., Budig, M., & Sun, H. (2004).
Why Are Some Academic Fields Tipping Toward Female. Stanford, CA: Stanford
RI
University. Retrieved April, 24, 2013.
SC
Essau, C. A., Conradt, J., & Petermann, F. (1999). Frequency and comorbidity of social
NU
phobia and social fears in adolescents. Behaviour research and therapy, 37(9), 831-843.
MA
Fang, A., Hoge, E. A., Heinrichs, M., & Hofmann, S. G. (2014). Attachment style
moderates the effects of oxytocin on social behaviors and cognitions during social
D
Fehm, L., Pelissolo, A., Furmark, T., & Wittchen, H. U. (2005). Size and burden of social
CE
accurate perception of competition in men and kinship in women. Social Cognitive and
Flynn, T. M., Markway, B. G., & Pollard, C. A. (1992). Fears of negative evaluation and
social phobia: Gender differences and relationship to depression, social sensitivity, and
assertiveness. Paper presented at the annual meeting of the Association for Advancement
39
ACCEPTED MANUSCRIPT
Fredrikson, M., Annas, P., Fischer, H., & Wik, G. (1996). Gender and age differences in
the prevalence of specific fears and phobias. Behaviour research and therapy, 34(1), 33-
39.
PT
Gater, R., Tansella, M., Korten, A., Tiemens, B. G., Mavreas, V. G., & Olatawura, M. O.
(1998). Sex differences in the prevalence and detection of depressive and anxiety
RI
disorders in general health care settings: report from the World Health Organization
SC
Collaborative Study on Psychological Problems in General Health Care. Archives of
NU
general psychiatry, 55(5), 405-413.
Goodwin, R., Koenen, K. C., Hellman, F., Guardino, M., & Struening, E. (2002).
MA
Gorka, S. M., Fitzgerald, D. A., Labuschagne, I., Hosanagar, A., Wood, A. G., Nathan, P.
PT
278-286.
AC
Griffiths, K. M., Nakane, Y., Christensen, H., Yoshioka, K., Jorm, A. F., & Nakane, H.
Japan. BMC psychiatry, 6(1), 21.Grossman, P., Wilhelm, F. H., Kawachi, I., & Sparrow,
40
ACCEPTED MANUSCRIPT
Guastella, A. J., Howard, A. L., Dadds, M. R., Mitchell, P., & Carson, D. S. (2009). A
Guimond, S., Chatard, A., Martinot, D., Crisp, R. J., & Redersdorff, S. (2006). Social
PT
Personality and Social Psychology, 90, 221-242. doi:10.1037/0022-3514.90.2.221
RI
review. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social
SC
phobia: Diagnosis, assessment, and treatment (pp. 261309). New York: Guilford Press.
NU
Heimberg, R. G., Stein, M. B., Hiripi, E., & Kessler, R. C. (2000). Trends in the
prevalence of social phobia in the United States: a synthetic cohort analysis of changes
MA
Heinrichs, M., von Dawans, B., & Domes, G. (2009). Oxytocin, vasopressin, and human
E
Hofmann, S. G., Asnaani, A., & Hinton, D. E. (2010). Cultural aspects in social anxiety
41
ACCEPTED MANUSCRIPT
Hoge, E. A., Lawson, E. A., Metcalf, C. A., Keshaviah, A., Zak, P. J., Pollack, M. H., &
patients with social anxiety disorder. Depression and anxiety, 29(11), 924-930.
Hoge, E. A., Pollack, M. H., Kaufman, R. E., Zak, P. J., & Simon, N. M. (2008).
Oxytocin levels in social anxiety disorder. CNS neuroscience & Therapeutics, 14(3), 165-
PT
170.
Hwu, H. G., Yeh, E. K., & Chang, L. Y. (1989). Prevalence of psychiatric disorders in
RI
Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatrica
SC
Scandinavica, 79(2), 136-147. NU
Katzelnick, D. J., & Greist, J. H. (2001). Social anxiety disorder: An unrecognized
Kessler R.C., Berglund P., Demler O., Jin R, Merikangas K.R., & Walters E.E. (2005).
D
Lifetime Prevalence and Age of Onset Distributions of DSM-IV Disorders in the National
E
doi:10.1001/archpsyc.62.6.593
CE
Kessler, R. C., Crum, R. M., Warner, L. A., Nelson, C. B., Schulenberg, J., & Anthony, J.
Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S.,
Wittchen, H.U., & Kendler, K. S. (1994). Lifetime and 12-month prevalence DSM-III-R
psychiatric disorders in the United States: results from the National Comorbidity
42
ACCEPTED MANUSCRIPT
La Greca, A. M., & Lopez, N. (1998). Social anxiety among adolescents: Linkages with
peer relations and friendships. Journal of abnormal child psychology, 26(2), 83-94.
Labuschagne, I., Phan, K. L., Wood, A., Angstadt, M., Chua, P., Heinrichs, M., ... &
PT
Nathan, P. J. (2010). Oxytocin attenuates amygdala reactivity to fear in generalized social
RI
SC
Labuschagne, I., Phan, K. L., Wood, A., Angstadt, M., Chua, P., Heinrichs, M., ... &
Lampel, L., Slade, T., Issakidis, C., & Andrews, G. (2003). Social phobia in the
D
Large, M. D., & Marcussen, K. (2000). Extending identity theory to predict differential
CE
Lecrubier, Y., Wittchen, H. U., Faravelli, C., Bobes, J., Patel, A., & Knapp, M. (2000). A
AC
European perspective on social anxiety disorder. European Psychiatry, 15, 5-16. doi:
10.1016/S0924-9338(00)00216-9
43
ACCEPTED MANUSCRIPT
Lun, J., Kesebir, S., & Oishi, S. (2008). On feeling understood and feeling well: The role
doi:10.1016/j.jrp.2008.06.009
MacKenzie, M. B., & Fowler, K. F. (2013). Social anxiety disorder in the Canadian
PT
disorders, 27(4), 427-434.
Maner, J. K., Miller, S. L., Schmidt, N. B., & Eckel, L. A. (2008). Submitting to defeat
RI
social anxiety, dominance threat, and decrements in testosterone. Psychological
SC
Science, 19(8), 764-768. NU
Marazziti, D., Abelli, M., Baroni, S., Carpita, B., Ramacciotti, C. E., & Dell'Osso, L.
20(2), 100-111.
D
Markus, H., & Kitayama, S. (1991). Culture and the self: Implications for cognition,
E
Marcus, S. M., Young, E. A., Kerber, K. B., Kornstein, S., Farabaugh, A. H., Mitchell, J.,
CE
... & Rush, A. J. (2005). Gender differences in depression: findings from the STAR* D
Marcussen, K., & Large, M. D. (2003). Using Identity Discrepancy Theory to Predict
Advances in Identity Theory and Research (pp. 151166). New York: Kluwer
Academic/Plenum.
Marom, S., GilboaSchechtman, E., Aderka, I. M., Weizman, A., & Hermesh, H. (2009).
44
ACCEPTED MANUSCRIPT
naturalistic study of cognitive behavior group therapy. Depression and Anxiety, 26(3),
289-300.
McCullough, M. E., Churchland, P. S., & Mendez, A. J. (2013). Problems with measuring
PT
trusted?. Neuroscience & Biobehavioral Reviews, 37(8), 1485-1492.
RI
McLean, C. P., Asnaani, A., Litz, B. T., & Hofmann, S. G. (2011). Gender differences in
SC
anxiety disorders: prevalence, course of illness, comorbidity and burden of
Merikangas, K. R., Avenevoli, S., Acharyya, S., Zhang, H., & Angst, J. (2002). The
E
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., ... &
Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980-989.
Meyer-Lindenberg, A., Domes, G., Kirsch, P., & Heinrichs, M. (2011). Oxytocin and
vasopressin in the human brain: social neuropeptides for translational medicine. Nature
45
ACCEPTED MANUSCRIPT
Moscovitch, D. A., Hofmann, S. G., & Litz, B. T. (2005). The impact of self-construals
Neumann, I. D., & Slattery, D. A. (2016). Oxytocin in general anxiety and social fear: a
PT
Ohayon, M. M., & Schatzberg, A. F. (2010). Social phobia and depression: prevalence
RI
SC
Osterlind, S. J., & Everson, H. T. (2009). Differential item functioning (Vol. 161). Sage
Publications.
NU
Oyserman, D., & Lee, S. W. S. (2008). Does culture influence what and how we think?
MA
Doi: 10.1037/0033-2909.134.2.311
D
Pakriev S, Vasar V, Aluoja A, Shlik J. (2000). Prevalence of social phobia in the rural
E
Parker, G., & Brotchie, H. (2010). Gender differences in depression. International Review
CE
Ranta, K., Kaltiala-Heino, R., Koivisto, A. M., Tuomisto, M. T., Pelkonen, M., &
Marttunen, M. (2007). Age and gender differences in social anxiety symptoms during
153(3), 261-270.
46
ACCEPTED MANUSCRIPT
Reid, A. (2004). Gender and sources of subjective well-being. Sex Roles, 51, 617-629.
doi:10.1007/s11199-004-0714-1
Roberts, K. E., Hart, T. A., Coroiu, A., & Heimberg, R. G. (2011). Gender role traits
PT
Rodebaugh, T. L., Fernandez, K. C., & Levinson, C. A. (2012). Testing the effects of
social anxiety disorder on friendship quality across gender and ethnicity. Cognitive
RI
behaviour therapy, 41(2), 130-139.
SC
Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., Stein, M. B., & Kessler, R. C.
NU
(2008). Social fears and social phobia in the USA: results from the National Comorbidity
Ryder, A. G., Yang, J., Zhu, X., Yao, S., Yi, J., Heine, S. J., & Bagby, R. M. (2008). The
D
Schneier, F., & Goldmark, J. (2015). Social Anxiety Disorder and Gender Differences. In
CE
Stein D.F., & Vythilingum, B. (Eds.), Anxiety Disorders and Gender (pp. 49-67).
Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R., & Weissman, M. M.
Schreier, S. S., Heinrichs, N., Alden, L., Rapee, R. M., Hofmann, S. G., Chen, J., ... &
Bgels, S. (2010). Social anxiety and social norms in individualistic and collectivistic
47
ACCEPTED MANUSCRIPT
Shear, M. K., Feske, U., & Greeno, C. (2000). Gender differences in anxiety
Shimizu, M., Seery, M. D., Weisbuch, M., & Lupien, S. P. (2011). Trait social anxiety
PT
Solyom, L., Ledwidge, B., & Solyom, C. (1986). Delineating social phobia. The British
RI
SC
Sparrevohn, R. M., & Rapee, R. M. (2009). Self-disclosure, emotional expression and
intimacy within romantic relationships of people with social phobia. Behaviour Research
NU
and Therapy, 47(12), 1074-1078.
MA
Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia:
10.1176/appi.ajp.157.10.1606
E
Stoyanova, M., & Hope, D. A. (2012). Gender, gender roles, and anxiety: Perceived
PT
Tabachnick, B. G., and Fidell, L. S. (2013). Using multivariate statistics, 6th ed. Boston:
AC
Pearson.
Tabak, B. A., Meyer, M. L., Dutcher, J. M., Castle, E., Irwin, M. R., Lieberman, M. D., &
Eisenberger, N. I. (2016). Oxytocin, but not vasopressin, impairs social cognitive ability
among individuals with higher levels of social anxiety: a randomized controlled trial.
48
ACCEPTED MANUSCRIPT
Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress
959.
Turk, C. L., Heimberg, R. G., Orsillo, S. M., Holt, C. S., Gitow, A., Street, L. L., ... &
PT
of anxiety disorders, 12(3), 209-223.
Vnnen, J. M., Frjd, S., Ranta, K., Marttunen, M., Helminen, M., & Kaltiala-Heino, R.
RI
(2011). Relationship between social phobia and depression differs between boys and girls
SC
in mid-adolescence. Journal of affective disorders,133(1), 97-104.
NU
van Honk, J., Bos, P. A., Terburg, D., Heany, S., & Stein, D. J. (2015). Neuroendocrine
Vesga-Lpez, O., Schneier, F., Wang, S., Heimberg, R., Liu, S. M., Hasin, D. S., &
D
Blanco, C. (2008). Gender differences in generalized anxiety disorder: results from the
E
Weisman, O., Zagoory-Sharon, O., Schneiderman, I., Gordon, I., & Feldman, R. (2013).
Plasma oxytocin distributions in a large cohort of women and men and their gender-
Wigton, R., Radua, J., Allen, P., Averbeck, B., Meyer- Lindenberg., A., McGuire, P.,
49
ACCEPTED MANUSCRIPT
Wittchen, H. U., Fuetsch, M., Sonntag, H., Mller, N., & Liebowitz, M. (2000).
Disability and quality of life in pure and comorbid social phobia: Findings from a
PT
Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999). Social fears and social phobia in a
community sample of adolescents and young adults: Prevalence, risk factors and co-
RI
morbidity. Psychological Medicine, 29, 309-323. doi: 10.1017/s0033291798008174
SC
Wu, P., Goodwin, R. D., Fuller, C., Liu, X., Comer, J. S., Cohen, P., & Hoven, C. W.
NU
(2010). The relationship between anxiety disorders and substance use among adolescents
adolescents and young adults with sucide attempts. European Archives of Psychiatry and
PT
Xu, Y., Schneier, F., Heimberg, R. G., Princisvalle, K., Liebowitz, M. R., Wang, S., &
Blanco, C. (2012). Gender differences in social anxiety disorder: Results from the
AC
Yonkers, K. A., Bruce, S. E., Dyck, I. R., & Keller, M. B. (2003). Chronicity, relapse, and
findings in men and women from 8 years of followup. Depression and anxiety, 17(3),
173-179.
50
ACCEPTED MANUSCRIPT
comparison of clinical course and characteristics of social phobia among men and
Ziegler, C., Dannlowski, U., Bruer, D., Stevens, S., Laeger, I., Wittmann, H., ... &
PT
for a role in social anxiety. Neuropsychopharmacology, 40(6), 1528-1538.
RI
SC
NU
MA
E D
PT
CE
AC
51
ACCEPTED MANUSCRIPT
Table 1
Gender differences in social anxiety disorder (SAD) prevalence among males and females with SAD
PT
diagnosis
Males Females
RI
Schneier, Johnson, > 13,000 young USA Lifetime SAD 2% 3.1% Yes
SC
Hornig, Liebowitz, adults (18-29)
(15-54)
Xu et al., 2012 43,093 adults USA Lifetime SAD 4.2% 5.7% Yes
D
2011
CE
Ohayon and 18, 980 U.K., Current SAD 3.4% 5.4% Yes
AC
and Portugal
52
ACCEPTED MANUSCRIPT
Lpine & Lellouch, 1787 adults France Lifetime SAD 2.l% 5.4% Yes
1995 (18+)
PT
Fowler, 2013 individuals
(15+)
RI
Pakriev, Vasar, 855 adults Russia Lifetime SAD 37.5% 51.8% Yes
SC
Aluoja, & Shlik, (18-65)
2000
NU
Cho et al., 2007 6275 adults Korea Lifetime SAD 0.1 0.4 No
(18-64) inferential
MA
tests were
reported
Hwu, Yeh, & 5,005, 3,004 Taiwan Lifetime SAD 2.4% 9.5% Yes-
D
and 6 rural
CE
villages)
1999 adolscents
(14-25)
2010 adolescents
(13- 18)
(12-17)
53
ACCEPTED MANUSCRIPT
PT
RI
SC
NU
MA
DE
PT
CE
AC
54
ACCEPTED MANUSCRIPT
Highlights
Findings indicate that women are more likely to have SAD compared to men.
Women with SAD report elevated severity and physiological arousal compared to
men.
PT
These differences are unlikely to be a result of reporting bias alone.
Despite the findings above, men with SAD seek treatment more than women.
RI
SC
NU
MA
E D
PT
CE
AC
55